Overview of enteric fistulas

Author:

Sharon L Stein, MD, FACS, FASCRS

Section Editors:

Eileen M Bulger, MD, FACS

J Thomas Lamont, MD

David I Soybel, MD

Deputy Editor:

Wenliang Chen, MD, PhD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.

Literature review current through: Dec 2018. | This topic last updated: Mar 20, 2017.

INTRODUCTION — A fistula is an abnormal connection between two organs. Enteric fistulas are
abnormal connections between the gastrointestinal tract and other abdominal organs, chest,
or skin. Symptoms associated with fistulas depend on whether the fistula is proximal (eg,
stomach, jejunum) or distal (eg, ileum, colon) and may include diarrhea for enterocolonic or
enteroenteric fistulas, urinary tract infections for fistulas to the urinary system, or external
drainage of enteric contents for enterocutaneous or enteroatmospheric fistulas.

The treatment of fistulas requires optimization of nutrition and healing potential, and
definitive surgical treatment, when indicated. Many enteric fistulas may heal spontaneously.
Nonoperative interventions such as endoscopic or interventional radiology can be used for
temporary or definitive management of fistulas. During evaluation, a thorough consideration
of the etiology of the fistula, removal of precipitating factors, optimization of nutritional
status, and primary treatment of fistulas should occur. Up to 25 percent of mortality from
fistulas occurs as a result of infection and sepsis related to complications from fistulas.
Additional mortality is often due to fluid and nutritional losses secondary to uncontrolled
fistula output. Immediate surgery may be required in the setting of uncontrolled sepsis.

An overview of the clinical features, diagnosis, and management of enteric fistulas is reviewed
here. Other enteric fistulas, including pancreatic fistulas, are introduced briefly below but
reviewed in more detail in separate topic reviews. (See "Pancreatic fistulas: Clinical
manifestations and diagnosis" and "Pancreatic fistulas: Management" and "Urogenital tract
fistulas in women" and "Rectovaginal and anovaginal fistulas" and "Anorectal fistula: Clinical
manifestations, diagnosis, and management principles".)
DEFINITION AND CLASSIFICATION — A fistula is an abnormal communication between two
structures.

Enteric fistulas can be classified as internal or external depending upon whether they drain
externally to the skin or internally to the gastrointestinal tract or other organ (eg, bladder,
vagina). Enteric fistulas are also classified with respect to the anatomic segments of bowel (ie,
other organs or vascular structures) that are involved [1].

The origin of the fistula is also important in diagnosis:

●Gastric

●Biliary

●Upper intestinal

●Colonic

The specific designation of enteric fistulas is based upon the segment of bowel or other organ
from which it originates (gastro-, duodeno-, entero-, jejuno-, ileo-, colo-, recto-, chole-) and the
point of termination (-cutaneous, -enteric, -colonic, -rectal, -vesical, -vaginal, -aortic).
However, at initial presentation, the specific segment of bowel involved is often unknown, and
the broader designation (eg, enterocutaneous rather than jejunocutaneous) can be used until
the anatomy of the fistula can be delineated. (See 'Diagnosis' below.)

Enteric fistulas are also classified with respect to the output of the fistula. The physiologic
consequences of enterocutaneous fistulas depend upon the composition of the fistula
drainage, which differs for proximal versus distal intestinal fistulas, and volume of the fistula.
The physiologic classification of enterocutaneous is as follows:

●A low-output fistula drains less than 200 mL/day

●A moderate-output fistula drains between 200 and 500 mL/day

●A high-output fistula drains more than 500 mL/day

Fistulas associated with Crohn disease are classified as:

●Type 1 – No evidence of active disease

●Type 2 – More complex fistulas associated with intra-abdominal abscesses

ETIOLOGY AND RISK FACTORS — Although various etiologies can lead to enteric fistula
formation (table 1), many fistulas occur in the postoperative setting. Approximately 20 to 30
percent of all enterocutaneous fistulas arise in the setting of Crohn disease (spontaneous,
following bowel resection) [2,3]. (See "Clinical manifestations, diagnosis and prognosis of
Crohn disease in adults", section on 'Fistulas'.)

The etiologic classification is based on the underlying disease process [2]. The mnemonic
"FRIEND" describes common etiologies for fistulas, which include foreign body, radiation,
inflammation or infection (eg, tuberculosis, actinomycosis), epithelialization, neoplasia, and
distal obstruction. Enteric fistulas may also be the result of iatrogenic injury during surgery or
traumatic injury.

Postoperative — Postoperative fistulas are the result of bowel injury during surgery, a leak
from a bowel anastomosis, missed enterotomy, or erosion of foreign material into adjacent
bowel (eg, mesh for hernia repair, vascular graft) [4]. Preoperative factors that increase the
likelihood of the development of a fistula include malnutrition, immunosuppression, traumatic
injury, infection, and emergency procedures [5,6].

Open abdomen — The increasingly common practice of damage control and leaving the
abdomen open for those at risk for abdominal compartment syndrome after trauma or
emergency surgery has led to the emergence of a particularly difficult-to-manage fistula, the
enteroatmospheric (exposed) fistula [2,7]. (See "Management of the open abdomen in
adults".)

Enteroatmospheric or exposed fistulas occur in the midst of an open abdomen with no

overlying soft tissue (picture 1). These are one of the most difficult complications of "damage
control" laparotomy and are a source of significant morbidity and mortality [7].
Enteroatmospheric fistula is classified on the basis of the surrounding abdominal wound [8]:

●A superficial exposed fistula drains atop the granulating wound of a frozen abdomen (densely
adherent intestines and other abdominal organs, also called fused visceral block) with an
obliterated peritoneal cavity and primarily represents a wound management and nutritional
support problem.

●A deep exposed fistula drains intestinal contents directly into the peritoneal cavity, causing
peritonitis, and is characterized by uncontrolled infection. This may require emergent surgical
intervention.

A review of 517 patients from the American Association for Surgery in Trauma (AAST) registry
with open abdomen found that independent risk factors for enterocutaneous fistula,
enteroatmospheric fistula, and intra-abdominal sepsis included large bowel resection, large-
volume resuscitation, and an increasing number of abdominal re-explorations [9].

Neoplasia — In a patient with a new primary fistula, without known medical risk factors or
prior surgery, consideration of a neoplastic process should occur. Generally, imaging and
endoscopic evaluation will elucidate this as a cause of fistula.

Radiation — Radiation, particularly pelvic radiation, may result in rectovaginal fistulas,

prostatic-urethral fistulas, or enteric fistulas.

CLINICAL FEATURES — The initial presentation of a fistula is often one of abnormal drainage.
Depending upon the location and origin of the fistula, this may be drainage through a prior
abdominal wound, the development of diarrhea or fecaluria, or gastrointestinal bleeding. It is
important to first assess the stability of the patient and determine the need for emergent
surgical intervention. If the fistula output can be controlled and there are no signs of
peritonitis, or uncontrolled sepsis, then initial evaluation should include imaging to determine
the source and etiology of the fistula. (See 'Diagnosis' below and 'Indications for fistula
resection' below.)

The most common presentation of an enteric fistula is that of an enterocutaneous fistula in a

postoperative patient who fails to recover normally from abdominal surgery. The patient may
exhibit abdominal discomfort, distension and tenderness, a low-grade fever, or signs of
abdominal sepsis. Most typically, a wound infection is recognized 7 to 10 days postoperatively,
and following incisional drainage, enteric contents appear in the surgical wound [4].

A superficial enteroatmospheric fistula can occur suddenly after injury to, or desiccation of, a
loop of exposed bowel, or it can evolve gradually as the open abdominal wound heals around a
deep fistula that has been effectively controlled. Enterocutaneous fistulas and
enteroatmospheric fistulas (particularly those deep to the open abdominal surface) can be
associated with intra-abdominal infection, either as a contained infection (intra-abdominal
abscess) or with generalized peritonitis. Symptoms may include abdominal pain; nausea
and/or vomiting; obstipation and other symptoms and signs of bowel obstruction; and/or
systemic signs such as fever, chills, or end-organ dysfunction, and even multisystem organ
failure. These features can also be present in patients with internal pancreatic fistulas as well.
(See "Pancreatic fistulas: Clinical manifestations and diagnosis", section on 'Internal fistulas'.)

The clinical presentation of other types of enteric fistula depends upon the segment of
intestine or other organs affected. Complaints may include:

●Diarrhea – Fistula between the proximal small bowel and distal bowel, or biliary tree and
small bowel.

●Passage of air in the urine (pneumaturia), recurrent urinary tract infections, or stool per the
vagina – Colovesical fistula, colorectal fistula, colovaginal fistula. (See "Urogenital tract fistulas
in women", section on 'Clinical presentation' and "Rectovaginal and anovaginal fistulas",
section on 'Clinical manifestations'.)

●Small bowel obstruction – Symptoms and signs of small bowel obstruction may be due to an
inflammatory mass or abscess, tumor, hernia, or adhesions. Gallstone ileus can occur if a
gallstone erodes into the adjacent small bowel, leading to obstruction. (See "Epidemiology,
clinical features, and diagnosis of mechanical small bowel obstruction in adults" and "Gallstone
ileus".)

●Gastrointestinal bleeding – Abdominal vascular communication with bowel, often in the

setting of prior graft placement or infection. (See "Overview of infected (mycotic) arterial
aneurysm" and "Aortoenteric fistula: Recognition and management".)

DIAGNOSIS — In the postoperative patient with wound drainage, or an open abdomen, the
diagnosis of postoperative enterocutaneous fistula or enteroatmospheric fistula may be
obvious based on the appearance of the fistula exit site and the character of enteric contents
in the wound; however, a definitive diagnosis of enteric fistula is made by demonstrating the
abnormal connection between the bowel and skin, or for internal fistulas, bowel-to-bowel or
other organs. For pancreatic fistulas, the diagnosis relies on the demonstration of an amylase
level in the drainage that is greater than three times the upper limit of the normal serum value
[10]. (See "Pancreatic fistulas: Clinical manifestations and diagnosis".)

Computed tomography (CT) of the abdomen with and without oral and intravenous contrast is
the initial study for patients suspected of having an enteric fistula. CT may demonstrate the
anatomy of the fistula and may also demonstrate associated intra-abdominal abscess, other
fluid collections, areas of distal intestinal obstruction, or pneumobilia in the case of gallbladder
fistulas. In patients with suspected enteric fistula for whom the diagnosis is in doubt, or when
anatomic detail provided by abdominal CT is not adequate, a gastrointestinal contrast study
(small bowel follow-through or contrast enema, depending upon the suspected level of the
fistula) may demonstrate the fistula. Alternatively, for enterocutaneous fistula that has a well-
defined cutaneous opening, in the absence of sepsis, a fistulogram can document intestinal
continuity and evaluate for distal obstruction [4,11,12]. However, the fistulogram rarely
identifies the specific origin of the tract [2]. The fistulogram is performed by injecting a water-
soluble contrast agent into the opening to first define the fistula tract. Subsequently, a
guidewire can be used to place an angiographic catheter using fluoroscopic guidance to further
define with additional contrast injections any associated pockets or cavities [12].

Small fistulas may not be apparent on imaging. A simple method to determine whether or not
an enteric fistula is indeed present is by the administration of dye (eg, indigo carmine,
methylene blue, charcoal), which can be injected intravenously, ingested or added to enteric
feeding, or instilled as a solution into the bladder or rectum using a catheter or during
endoscopy. The appearance of blue staining in wound drainage, urine, feces, or from the
vagina confirms that an enteric fistula is present but provides no further information. The
subsequent diagnosis of urogenital or rectal fistulas may require examination under anesthesia
to visually confirm the presence of a fistulous tract using probes. Endoscopic evaluation of
both vagina and rectum can also help elucidate the source of the fistula. (See "Urogenital tract
fistulas in women", section on 'Cystoscopy and imaging studies'.)

DIFFERENTIAL DIAGNOSIS — Drainage from an abdominal incision following gastrointestinal

surgery may represent a surgical site infection rather than enteric fistula. The character of the
drainage, and lack of persistence of the drainage once the wound has been opened, usually
makes the distinction. (See "Wound infection following repair of abdominal wall hernia".)

Inflammatory processes that result in localized gastrointestinal perforation may initially

present as an intra-abdominal abscess, which may not be associated with an enteric fistula.
(See "Overview of gastrointestinal tract perforation".)

Internal fistulas that present with diarrhea are generally associated with predisposing factors
(eg, prior surgery, inflammatory bowel disease, history of radiation therapy) [13-15]. However,
diarrhea due to spontaneous fistula without predisposing factors may need to be distinguished
from other causes. (See "Approach to the adult with acute diarrhea in resource-rich settings".)

INITIAL MANAGEMENT — Initial treatment of enteric fistulas focuses on the correction of fluid
and electrolyte imbalance, treatment of infection, abscess drainage (if needed), nutritional
support, and, for external fistulas (including pancreatic), control of the effluent drainage and
skin care (table 2).
Fluid therapy — Aggressive correction of hypovolemia and electrolyte loss should occur early
in treatment. Hypokalemia is the most common electrolyte abnormality. Ongoing fluid losses
from high-output upper gastrointestinal fistulas should be replaced with isotonic saline and
potassium supplementation with serial measurements of serum electrolytes. High-output
fistulas may require electrolyte analysis of the fistula effluent to make an appropriate choice of
fluid replacement. Repleting fluid losses cc per cc may be necessary to help prevent
dehydration and hypovolemia. (See "Treatment of hypovolemia or hypovolemic shock in
adults" and "Clinical manifestations and treatment of hypokalemia in adults".)

Duodenal or pancreatic fistulas may require bicarbonate replacement because of the

development of metabolic acidosis. (See "Pancreatic fistulas: Management" and "Approach to
the adult with metabolic acidosis", section on 'Overview of therapy'.)

Treatment of infection — Associated infection (eg, abscess formation) and abdominal sepsis
related to gastrointestinal perforation as a cause of enteric fistula needs to be recognized and
promptly treated with antibiotics and, when necessary, with surgery to reduce the risk of
progressive organ dysfunction or failure [16,17]. Recognition of an incompletely drained fistula
is important, as is treatment of cellulitis associated with fistula.

●Peritonitis is a surgical emergency requiring laparotomy to control the source of infection. In

cases of uncontrolled sepsis, this most often requires exteriorization of the fistula or control of
the fecal stream by diversion (ie, ostomy). Rarely, an early fistula can be resected or closed
primarily.

●Percutaneous abscess drainage with radiologic guidance (ultrasound or CT) is often possible
[12]. Drainage is usually performed through the anterior abdominal wall. However, abscesses
deep in the pelvis or obscured by other organs may be accessed with a variety of approaches,
including transgastric, transrectal, transvaginal, and transgluteal [18]. The drainage catheter is
usually left in place until drainage is less than 10 mL in 24 hours, which may take as long as 30
days. Catheter fistulograms during this period permit assessment of resolution of the abscess
cavity. Surgical intervention is needed if improvement does not occur. (See "Overview of
gastrointestinal tract perforation", section on 'Conservative care' and "Pancreatic fistulas:
Management", section on 'Percutaneous drainage'.)

●Covered enteric stents have been used to treat early postoperative leaks of the colon and
esophagus. This therapy may help control the initial leak and limit infection, allowing the
patient to stabilize until interim definitive management can be undertaken. (See
"Management of anastomotic complications of colorectal surgery" and "Complications of
esophageal resection".)

Nutritional support — Patients with an enteric fistula should not be allowed to eat (NPO [nil
per os]) during the initial stage of treatment until the source of the fistula is controlled.
Nutritional support should be initiated slowly after correction of fluid, electrolyte, and vitamin
deficits [19-21]. (See "Nutrition support in critically ill patients: An overview".)

Baseline requirements for carbohydrates, fat, and protein are increased for patients with
ongoing peritonitis, large open abdominal wounds, and high-output fistulas, and range from 20
to 30 kcal/kg per day of carbohydrates and fat, and 0.8 to 2.5 g/kg per day of protein. The
addition of fish oil or omega-3 fatty acids improves immune function [22]. Although
randomized trials have demonstrated lower infection rates after severe injury [23], abdominal
operation [24], and in patients in the intensive care unit [25], there are no trials investigating
the effect of omega-3 fatty acid nutritional supplements specifically in the treatment of
enterocutaneous fistula.

If fistula output is low to moderate, many patients may be allowed to eat. Enteral feedings are
preferred because this route preserves the intestinal mucosal barrier and has positive effects
on immunologic and hormonal gut function. However, enteral feedings are often impractical
because of feeding intolerance, lack of access to the gastrointestinal tract, or increased fistula
output [26]. Thus, some patients require parenteral nutritional support.

CONTROLLING EXTERNAL FISTULA OUTPUT — The main goal in managing external fistulas is to
control the enteric contents at the source of the fistula to protect the skin from the corrosive
effects of the enteric or pancreatic contents, and to facilitate nursing care of the patient.

Bag drainage — Skin protection creams and effluent collection bags must be tailored to the
unique characteristics of each fistula, but the principles are similar to those used in the care of
a colostomy or ileostomy [27]. The assistance of a skilled enterostomal therapist is helpful.
(See "Routine care of patients with an ileostomy or colostomy and management of ostomy
complications".)

●For enterocutaneous and pancreatic fistulas, a sump or pouch should be placed around the
fistula. The adjacent skin should be protected (eg, semipermeable barrier dressing or with
other skin protectants). Wound protectors and wound managers may be used to minimize skin
irritation and collect effluent as with surgical ostomy. (See "Routine care of patients with an
ileostomy or colostomy and management of ostomy complications", section on 'Pouch system
and routine care'.)

●Control of intestinal contents from an enteroatmospheric fistula will minimize damage to the
healing bed of granulation tissue until definitive closure of the fistula can be undertaken 6 to
12 months later. Control may require a surgical diversion to convert the gastrointestinal
opening into a stoma that can be controlled. (See 'Enteroatmospheric fistula' below.)

Pharmacologic therapy — Anticathartics and somatostatin analogs have been used to reduce
the output from intestinal fistulas. These are discussed below.

For the uncommon bilioenteric fistula (eg, biliary-colonic), cholestyramine can be tried. It is
available in powder form and dosed at 9 gm twice daily prior to meals. Each of these
medications can be used for the treatment of diarrhea, with anecdotal evidence of decreased
fistula output.

Anticathartics — Anticathartics such as loperamide hydrochloride (Imodium) and

diphenoxylate-atropine (Lomotil) may be used for diarrhea and high-output fistulas.
Loperamide is available in 2-mg tablets over the counter, while diphenoxylate requires a
prescription for 2.5-mg tablets. Patients should titrate the dosage to output, with a maximal
dose of 16 mg of loperamide daily and 20 mg of diphenoxylate. Both are also available in liquid
form, which may be more useful for patients with poor absorption. Both medications are also
best used approximately 20 minutes prior to the consumption of foods.

Somatostatin analogues — Intestinal fistula output can be reduced with somatostatin and its
analogues (eg, octreotide). Conservative nonoperative management of fistulas associated with
Crohn disease includes other pharmacologic therapy [28]. (See "Overview of medical
management of high-risk, adult patients with moderate to severe Crohn disease", section on
'Fistulizing disease'.)

Somatostatin reduces fistula output, but its practical clinical use is limited by a very short half-
life. Octreotide, with a half-life of two hours, reduces gastrointestinal secretions and facilitates
absorption of water and electrolytes. A systematic review identified eight trials and found that
somatostatin analogues decrease the duration of enterocutaneous fistulas (weighted mean
difference [WMD] -6.37 days, 95% CI -8.33 to -4.42) and duration of hospital stay (WMD -4.53
days, 95% CI -8.29 to -0.77) [29]. A separate review found similar results but noted that
somatostatin had a larger effect compared with somatostatin analogues [30]. Octreotide does
not significantly reduce the need for operation in patients with Crohn disease fistulas [31,32].
Octreotide may adversely affect immune function as a result of growth hormone inhibition
[33,34], but there are no clinical data to confirm this possibility. It is also important to keep in
mind that if the patient has one of the barriers to spontaneous closure (table 3), such as distal
obstruction, octreotide will be futile and will delay the surgical procedure ultimately needed to
obtain definitive closure.

Negative pressure wound therapy — Although there are no large studies comparing negative
pressure wound therapy (picture 2) with traditional drainage bags, the use of negative
pressure wound therapy in fistula management has become widespread because surgeons are
familiar with the technology from its successful application to other problematic wounds [35].
Negative pressure wound therapy may accelerate fistula closure by promoting wound healing
[36,37]. (See "Negative pressure wound therapy", section on 'Mechanism of action'.)

Negative pressure wound therapy can also simplify management of enteroatmospheric fistula.
Continuous suction of the fistula output minimizes contact time between intestinal fluid and
exposed peritoneum, thus effectively controlling intestinal spillage. A useful technique for
superficial enteroatmospheric fistula(s) is to intubate the fistula(s) and bring the tubes out
perpendicularly through the sponge of the negative pressure dressing (figure 1) [8]. With this
technique, the majority of intestinal effluent is collected in the tubes. The sponge serves as a
stable rig that anchors the tubes, prevents dislodgement, and collects any residual fluid that
might leak around the tubes. A study of vacuum-assisted wound management of 179 fistulas in
91 patients reported spontaneous closure in 46 percent within 90 days [38]. Among the others,
the closure rate was 84 percent. Overall mortality rate was 16 percent.

Care must be used when applying a negative pressure wound dressing in the setting of
exposed, but uninvolved, bowel because the dressing can cause formation of additional
fistulas, especially if fresh suture or staple lines in the bowel are exposed [39,40]. Additional
protection can be provided by placing another layer of plastic or a biologic dressing between
the bowel and the negative pressure sponge [41]. (See "Negative pressure wound therapy".)
Enteroatmospheric fistula — Immediate surgery is indicated for patients with a deep
enteroatmospheric fistula to contain spillage of enteric contents and manage peritonitis.
Thereafter, the fistula drainage should be controlled, fecal stream diverted, and the abdominal
wound allowed to granulate and heal around the fistula in anticipation of definitive closure at
a later time. Most patients with deep enteroatmospheric fistula will not have any option for
early fistula closure. Because superficial enteroatmospheric (exposed) fistulas will not heal
spontaneously due to the absence of overlying soft tissue, surgery will be needed to cover the
exposed bowel.

Superficial — Direct local closure can be attempted, but in most cases, superficial
enteroatmospheric fistula will require placement of skin grafts to the surrounding granulation
tissue to allow placement of a stoma appliance. After the grafts heal, stoma management can
be adapted to the specific requirements of the fistula. (See 'Bag drainage' above.)

●Direct local closure of the fistula – Although resection of the involved loop of bowel is the
most definitive treatment to manage fistulas (see 'Fistula resection' below), direct suture
closure of small "bud" fistulas associated with an open abdomen is sometimes possible [42].
This entails very limited dissection to define the edges of the fistula opening, followed by
extraperitoneal two-layer suture repair of the hole in the bowel on the surface of the
granulating abdominal wound. The key principle is to cover the suture line with a biological
dressing (autogenous or cadaveric skin graft, or acellular dermal matrix), with or without a
tissue adhesive. Although the procedure may not be successful approximately half the time,
this is a local, low-risk procedure that can be easily repeated [41,43].

●Conversion of the fistula into a controlled stoma – If local closure fails, coverage of the
granulating wound surrounding the fistula will generally be necessary to provide stable wound
coverage for fitting a stoma appliance or for using a negative-pressure wound dressing to
control fistula output. Autogenous skin grafts or acellular dermal matrix can be used and fixed
into place with fibrin glue [43-45]. (See 'Negative pressure wound therapy' above.)

Deep — Achieving control of intestinal spillage in the setting of a deep enteroatmospheric

fistula can be challenging. Exteriorization or proximal diversion is often difficult because of
massive edema of both the viscera and abdominal wall, as well as mesenteric thickening and
foreshortening. Tube drainage of the deep, enteroatmospheric fistula is not practical or useful
and may result in an enlarged opening with intestinal contents leaking around the tube.

The creation of a "floating stoma" can gradually convert a deep enteroatmospheric fistula into
a superficial fistula over a period of several weeks [46]. To create a floating stoma, the edge of
the hole in the gut is sutured to a similar-sized hole tailored in a plastic sheet that serves as a
temporary abdominal closure device and separates the intestinal drainage from the open
peritoneum. An ostomy bag can then be applied to the plastic sheet around the improvised
stoma, protecting the peritoneal cavity and allowing the wound to granulate.

FISTULA CLOSURE WITH CONSERVATIVE MANAGEMENT — Spontaneous closure rates vary

depending upon the cause and volume of the fistula. Predictors of spontaneous closure are
given in the table (table 3) [47,48]. Barriers to closure include distal obstruction, a short
epithelialized fistula tract, infection, and malignancy [47,49]. Given that enteroatmospheric
fistula is an exposed hole in the bowel lumen without overlying skin or soft tissue, it is not
surprising that there should be no realistic expectation of spontaneous closure.

Approximately one-third of enterocutaneous fistulas will close spontaneously within five to six
weeks with conservative measures [50-52]. Generally, low-output, long track, and proximal
small bowel are most likely to heal with conservative measures. In one retrospective review of
79 patients with enterocutaneous fistula, spontaneous closure occurred in 23 (29 percent)
after a median of 39 days (range 7 to 163) [53]. With modern management strategies, most
modern series report a mortality rate of 10 to 20 percent (table 4) [2,4,31,53-55].

As long as fistula output is gradually decreasing and the wound (or tract) shows signs of
healing, surgery should be delayed [38]. Patients who do not respond to an adequate trial of
supportive therapy should be referred to a center capable of providing complex
multidisciplinary care [56]. Treatment of enteral fistulas in specialized centers of excellence
improves outcomes and decreases mortality rates [2,55,57].

INDICATIONS FOR FISTULA RESECTION — Patients with enterocutaneous fistula who have
failed five to six weeks of nonoperative management will likely need surgery to definitively
manage the fistula. In a review of 79 patients with enterocutaneous fistula, 49 required
operative repair after a median of 101 (range 7 to 374) days; closure was achieved in 47 (96
percent) [53]. Although the timing of definitive surgery to close the fistula is a matter of
judgment, once it has been determined that the fistula is not likely to resolve on its own,
surgery should generally not be undertaken for another few months to lessen the risk for
bowel injury. Imaging should be repeated to ensure that fluid collections are drained, and
inflammation has resolved. Dense adhesions begin to form in the open abdominal wound after
approximately one week of exposure and remain treacherous for at least six to eight weeks.
The presence of a fistula is usually associated with a severe inflammatory response that leads
to dense adhesions, known as "obliterative peritonitis," that make early surgery hazardous
[48,58].

In addition to issues related to adhesion formation, definitive management of an

enteroatmospheric fistula should not be considered until the skin graft is supple and can be
pinched between the thumb and index finger, which signifies the existence of a plane between
the graft and underlying bowel [59]. This signifies that there is a tissue plane between the skin
graft and the gut, facilitating one of the more difficult steps of abdominal wall reconstruction,
which is dissection of the skin graft off the bowel.

Contraindications — Before considering definitive repair of an enteric fistula that has failed to
close spontaneously, the patient should be nutritionally replete, free of infection, and have
supple soft tissues adjacent to the fistula [2,60]. Known barriers to fistula closure should be
sought and treated prior to, or concurrent with, the fistula surgery (table 3). Additionally,
imaging should be performed to rule out source of distal obstruction and assess for Crohn
disease, radiation, or other characteristics that increase the likelihood of recurrence. (See
'Diagnosis' above.)

SURGERY — Studies evaluating surgical techniques for managing enteric fistulas generally
involve small cohorts of patients, multiple surgeons, and multiple institutions with significant
heterogeneity in fistula etiology, preoperative preparation, operative technique and skill level,
and postoperative care and wound management [61]. Most studies are limited to specific
populations (eg, patients with inflammatory bowel disease) or limited to specific types of
fistula (eg, small-bowel fistulas only). Thus, the surgical approach described below is based
primarily upon expert opinion and our clinical experience. The aim of surgery is to eliminate
the fistula, which usually requires resection of the segment of bowel that is the origin of the
fistula, reestablishment of gastrointestinal continuity, and tension-free closure of the
abdomen with well-vascularized soft tissue [2]. Liberal use of fecal diversion and bowel rest
during the postoperative healing should be used.

Prior to surgery, the surgeon should mark potential stoma sites, particularly in patients with
Crohn disease or diverticular disease, and consider placing ureteral stents if colon mobilization
is anticipated. (See "Overview of surgical ostomy for fecal diversion", section on 'Preparation
and counseling' and "Placement and management of indwelling ureteral stents", section on
'Prophylactic'.)

Incision and adhesiolysis — For patients with an intact abdominal wall, the incision site should
be chosen to avoid adhesions and regions where bowel loops may be adherent to the
abdominal wall at the site of prior incisions. Planning the surgical incision should also take into
consideration the potential need for complex abdominal wall reconstruction, such as
component separation, which requires that the abdominal wall soft tissue remain well
vascularized.

Once the incision is made, lysis of adhesions is performed to free the abdominal wall
circumferentially from adherent bowel. Several reports have been published describing various
techniques for approaching and finally resecting the involved bowel loop [42]. Expert surgeons
recommend working laterally first to take down adhesions and deliver the bowel from the side
of the abdomen least involved [4]. The adhesions are often dense, and the dissection should
be slow and careful. The surgeon must be prepared to spend hours performing painstaking
meticulous adhesiolysis and mobilizing the entire length of the gastrointestinal tract from the
ligament of Treitz to the rectum, if necessary, to identify the fistula and approach it safely [2].
It is usually not advisable to schedule other major elective operations on the same day because
these demanding procedures are often "all-day cases."

Several techniques can be used to facilitate the dissection of dense adhesions. We inject
isotonic saline into areas of dense adhesions. Others have reported placing an antibiotic-
soaked (cefazolin or kanamycin) sponge on areas of difficult adhesions [4]. Both methods help
to reveal the plane between the loops of bowel. Once the affected bowel segment(s) have
been resected, a gastrostomy tube and feeding jejunostomy should be placed. Any inadvertent
enterotomies or large serosal defects made during adhesiolysis should be carefully repaired.

Fistula resection — Once the fistula has been clearly defined, the segment of bowel that
contains the origin of the fistula is resected and gastrointestinal continuity reestablished. (See
"Bowel resection techniques".)

For patients with Crohn disease, complete resection of the enterocutaneous fistula, as well as
the adjacent diseased bowel, is necessary to prevent recurrence [62]. Wedge resections or
oversewing the fistula should be reserved only for patients with short bowel syndrome and
those who cannot afford to lose more functioning gut.

Special circumstances

Duodenal fistula — Duodenal fistulas are managed differently from other enteric fistulas
[54,63]. Duodenal fistulas result from sphincterotomies, perforated duodenal ulcers, or
following gastric resection. Although the majority of duodenal fistulas will heal with
nonoperative management (in the absence of distal obstruction), those that fail to heal are
best treated with gastrojejunostomy rather than resection, which would require
pancreaticoduodenectomy. (See "Postgastrectomy duodenal leak".)

Urogenital tract fistulas — Surgical techniques to repair enteric fistulas that involve the lower
gastrointestinal tract or urogenital tract are discussed elsewhere. (See "Rectovaginal and
anovaginal fistulas" and "Aortoenteric fistula: Recognition and management".)

Abdominal wall closure or reconstruction — Once the fistula is resected and gastrointestinal
continuity restored, the abdomen should be closed using standard techniques, provided this
will not result in undue tension. (See "Principles of abdominal wall closure".)

The goal of the definitive surgery in the management of enteroatmospheric fistula, besides
closing the fistula, is to reconstruct the abdominal wall with durable, well-vascularized tissue.
A two-team approach has the advantage of providing a well-rested plastic surgeon focused on
reconstruction after a long and tedious visceral dissection by the general surgery team [2].
Closure of large or complex abdominal wall defects associated with enteroatmospheric fistulas
may require advancement flap techniques. One option for abdominal closure is the
component separation technique, provided the rectus abdominis muscle remains intact [64].
Defects up to 10 cm in the upper abdomen, 20 cm in the midabdomen, and 8 cm in the lower
abdomen can be closed using this technique. Other options may include random, pedicle, or
free flaps with microvascular reconstruction. (See "Overview of abdominal wall hernias in
adults" and "Component separation repair of large or complex abdominal wall defects".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials,
"The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain
language, at the 5th to 6th grade reading level, and they answer the four or five key questions
a patient might have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials. Beyond the Basics patient
education pieces are longer, more sophisticated, and more detailed. These articles are written
at the 10th to 12th grade reading level and are best for patients who want in-depth
information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles on
a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Enteric (including enterocutaneous) fistula (The
Basics)")
SUMMARY AND RECOMMENDATIONS

●A fistula is an abnormal connection between two organs. Enteric fistulas communicate

between the lumen of the gastrointestinal tract and the skin or other organ such as another
segment of intestine, the bladder, vagina, rectum, or a vessel. (See 'Introduction' above.)

●The majority of enteric fistulas occur in the postoperative setting (includes those related to
the open abdomen, vascular surgery). Approximately 20 to 30 percent of enterocutaneous
fistulas arise in the setting of Crohn disease (spontaneous, following bowel resection). Other
spontaneous enteric fistulas can be due to a variety of other etiologies such as infectious
diseases, malignancy, following radiation therapy, perforated duodenal ulcer (duodenal
fistula), or vascular infection (table 1). (See 'Etiology and risk factors' above.)

●The clinical presentation and treatment of enteric fistulas depends upon the nature of the
connection and the presence of complicating factors, which may indicate the need for
immediate surgery. Typical clinical symptoms of external fistulas include wound drainage and
variable amounts of abdominal discomfort. Other symptoms related to enteric fistula include
diarrhea, abnormal passage of air in the urine or via the vagina, symptoms of small bowel
obstruction, or gastrointestinal bleeding (enteric communication with a vessel). (See 'Clinical
features' above.)

●The diagnosis of external fistulas may be obvious based upon the appearance of fistula exit
site and character of enteric contents in the wound; however, a definitive diagnosis is made by
demonstrating the abnormal connection between the bowel and skin, or for internal fistulas,
bowel-to-bowel or other organs, usually via imaging or endoscopy. We suggest computed
tomography (CT) of the abdomen as the initial study for patients suspected to have an enteric
fistula. Other methods of identifying and characterizing enteric fistulas include gastrointestinal
contrast studies, instillation of dye (eg, indigo carmine, methylene blue, charcoal), endoscopy,
and examination under anesthesia. (See 'Diagnosis' above.)

●Initial treatment of enteric fistulas focuses on fluid therapy to correct volume and electrolyte
deficits; treatment of infection, which may include drainage of intra-abdominal abscess;
correction of malnutrition; and controlling drainage from external fistulas. Approximately one-
third of enterocutaneous fistulas heal spontaneously with these measures. Patients who do
not respond to conservative measures will require surgical management and should be
referred to a center capable of providing complex multidisciplinary care. (See 'Initial
management' above.)

●Unlike enterocutaneous fistulas, enteroatmospheric fistulas will not heal spontaneously

because of the absence of overlying soft tissue. Immediate surgery is indicated for patients
with a deep enteroatmospheric fistula to contain spillage of enteric contents and managing
peritonitis. Drainage from superficial or deep fistulas is controlled until skin grafts can be
applied to the granulation bed to allow bag drainage of the stoma(s). Definitive surgical closure
of the fistula should not be considered until the skin graft is supple and can be pinched
between the thumb and index finger, which signifies the existence of a plane between the
graft and underlying bowel. (See 'Controlling external fistula output' above and 'Surgery'
above.)
●The goals of definitive surgery are to resect the fistula, reestablish gastrointestinal continuity,
and provide a tension-free closure of the abdomen with well-vascularized soft tissue. Before
consideration of definitive repair of fistulas that fail to close spontaneously, patients should be
nutritionally replete, free of infection, and have supple soft tissues adjacent to the fistula. (See
'Surgery' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate, Inc. would like to acknowledge Dr.
William Schecter, who contributed to an earlier version of this topic review.